Patient Care Coordinator

About the Role

Role Type: Full-Time 

Reporting To: Nurse-in-Charge 
Location: On-site at designated health centers within Brunei-Muara District, Brunei Darussalam 
Project: CARDIO4Cities Brunei

Job Summary: 

The Patient Care Coordinator will support the implementation of the CARDIO4Cities initiative across its various workstreams. Responsibilities will include patient engagement and outreach activities—such as re-engaging patients with chronic diseases who have missed or are overdue for follow-up care—as well as administrative, coordination, and data management support for other initiative activities as required.

This is a strictly non-clinical role. The successful candidate will be responsible for contacting patients using approved communication scripts, coordinating follow-up appointments with the nursing team, maintaining accurate records of outreach activities, and escalating any clinical concerns to the appropriate healthcare team. 

The role requires a warm and respectful approach when communicating with patients, as well as strong attention to detail when maintaining patient-related administrative information. 

Key Responsibilities1. Patient Re-engagement and Outreach

• Contact patients who have missed or are overdue for chronic disease follow-up appointments through approved phone calls or messaging channels. 
• Use approved communication scripts and follow established procedures when communicating with patients.
• Encourage patients to return for their scheduled follow-up care in a warm, respectful, and non-judgmental manner. 
• Record patient responses and outreach outcomes accurately and promptly.
• Follow up with patients as required in accordance with the established outreach process.

2. Appointment and Care Coordination

• Work closely with the nursing team to coordinate follow-up appointments for patients who agree to return for care. 
• Assist with scheduling relevant investigations and/or follow-up appointments as directed by the nursing team. 
• Ensure appointment information and patient responses are accurately recorded in the relevant system or database. 
• Support the nursing team with administrative coordination related to patient re-engagement activities.  

3. Non-Clinical Role Boundaries and Escalation 

• Adhere strictly to the boundaries of a non-clinical role. 
• Do not provide medical advice, clinical recommendations, diagnosis, or treatment guidance to patients. 
• Follow applicable procedures regarding access to and handling patient information. The patient care coordinator must not access confidential medical records, except where access to specific administrative information (such as appointment details) is expressly authorized in writing by the nurse-in-charge and is strictly necessary to perform the duties of the role. 
• Recognize and promptly escalate any clinical concerns, urgent symptoms, or other red flags reported by patients to the nursing team in accordance with established protocols to ensure timely clinical intervention. 
• Refer patients to the appropriate healthcare professional whenever a matter falls outside the scope of the role. 

4. Database and Activity Management  

• Maintain accurate and up-to-date records relating to patient outreach and follow-up activities. 
• Record call and messaging outcomes, patient responses, appointment arrangements, and other relevant activity accurately. 
• Identify and report inconsistencies or missing information in the relevant database or records to the nursing team for resolution. 
• Maintain proper documentation to support accurate tracking of patient re-engagement activities and outcomes. 
• Handle all patient-related information securely and in accordance with applicable policies and procedures. 

Required skills and qualifications

1. Communication and Patient Engagement 

• Strong interpersonal skills, with the ability to communicate respectfully and effectively with patients, colleagues, and healthcare teams. 
• Warm, empathetic, and non-judgmental telephone manners. 
• Good listening and problem-solving skills. 
• Ability to communicate sensitive matters professionally and respectfully. 
• Fluent in spoken and written Bahasa Melayu and English. 

2. Computer and Data Skills 

• High level of computer and data literacy, with confidence in using common workplace software to organize, update, and secure patient records. 
• Strong working knowledge of Microsoft Excel or Google Sheets, including advanced spreadsheet functions, meticulous data logging, activity tracking, and reporting. 
• Strong attention to detail when entering, updating, and checking information. 
• Ability to maintain organized and accurate records. 

3. Compliance and Professional Conduct 

• Demonstrates a strong understanding of confidentiality and the importance of protecting patient information. 
• Able to follow Ministry of Health policies, applicable data protection requirements, and relevant workplace procedures. 
• Maintains a high level of professionalism, integrity, and respect when dealing with patients and healthcare professionals. 
• Able to work independently while also working effectively as part of a healthcare team. 

4. Performance and Accountability 

• Able to meet agreed weekly performance targets for the number of patients successfully contacted and logged. 
• Consistently records outreach activities and outcomes accurately and within the required timeframe. 
• Demonstrates reliability, organization, and accountability in completing assigned tasks. 

Why Join Us? 

• Contribute to the implementation of CARDIO4Cities in Brunei Darussalam, a population health initiative focused on improving cardiovascular health. 
• Play a direct role in helping patients return to appropriate follow-up care and supporting better management of chronic disease. 
• Work alongside healthcare professionals and contribute to a meaningful health initiative involving local and international partners.  
• Gain practical experience in patient engagement, healthcare coordination, data management, and population health.

Additional Context: 

Despite being largely preventable, cardiovascular disease (CVD) is the world’s leading cause of death, causing significant strain on countries’ health systems and economies, especially in cities, where most of the global population lives. Each year, more than 20 million people die from CVD, of which 75% occur in low- and middle-income countries, many prematurely before the age of 60. Meanwhile, high-income countries are experiencing a resurgence of CVD, disproportionately so in underserved populations.  

By 2050, 70% of the world’s population will be urban, and cities will face a growing burden of CVD, compounded by rising inequities linked to social, economic, and environmental determinants of health, along with limited healthcare infrastructure and a shortage of skilled health workers. This calls for reimagining the way we address CV health, adopting a new approach that addresses both the medical and social determinants driving CVD, and cities are the best places to start.  In response, the Novartis Foundation established the CARDIO4Cities initiative. CARDIO4Cities consists of six interdependent pillars to accelerate and improve access to quality CV health and care, creating more livable, heart-healthy cities. The six pillars of CARDIO are quality of care, early access, policy reform, data and digital, intersectoral collaboration, and local ownership. The approach provides a framework to rapidly reduce overall CV risk in urban populations that is science-backed and offers concrete guidance on how to design and implement city-wide CV health interventions that are tailored to local priorities and needs. 

CARDIO4Cities has already reached over 40 million people, demonstrating the scalability of the approach. Validated in three pioneering cities—São Paulo (Brazil), Dakar (Senegal), and Ulaanbaatar (Mongolia)—the CARDIO4Cities initiative has demonstrated strong results, including: 

• Rapid improvement in heart health: In pioneering cities, control rates for blood pressure increased 3-6x within 1 year of implementation1, translating into an estimated reduction in strokes and heart attacks of 12% respectively 13%.  
• Proven cost-effectiveness: In pioneering cities, the initiative had a 76% lower cost per QALY gained compared to costing benchmark2 and is determined to be cost-effective under WHO-CHOICE3. Accelerated detection and management of CV risk: Using a data-driven approach, CARDIO4Cities has proven successful in optimizing diagnosis of CV risk factors within and outside health facilities and improving risk factor management by simplifying and streamlining guidelines and translating them into clinical decision support tools for health providers (incl. team-based care).